HEART SOUNDS: the firm muscle of the left ventricle and the

cardiac apex is close to the anterior chest wall

during systole
2. lower part of the sternum xiphoid process (the
right-ventricular area) - for the tricuspid valves
3. Valves of the pulmonary trunk are best heard
at its anatomical projection onto the chest, i.e.
in the second intercostal space, to the left of
the sternum.
4. aortic valves are best heard in the second
intercostal space, to the right of the sternum
where the aorta is the nearest to the anterior
chest wall
5. heart sounds which are associated with the
1 SOUND (systolic): contractions of aortic and mitral valves or
which develop during its affections can be
- Valve component: Vibrations of the cups of the
heard to the left of the sternum at the 3-rd and
atrioventricular valves (mitral and tricuspid
4-th costosternal joints (the so-called fifth
valve) when valves are closed.
listening post at the Botkin-Erb point).
- Muscular: myocardial isometric contraction
- Vascular component: vibrations of the nearest ORDER OF AUSCULTATION:
portions of the aorta and the pulmonary trunk.
The valve sounds should be heard in decreasing order of
Its longer and louder than the 2 sound. their affection frequency. The mitral valve should be
heard first (at the heart apex); next follows the aortic
2 SOUND (diastolic):
valve (in the second intercostal space to the right of the
- Vibrations of the semilunar cusp of the aortic sternum), the pulmonary valve (in the second
and pulmonary valve closure. intercostal space, to the left of the sternum), tricuspid
- Vascular component: vibration at the valve (at the base of the xiphoid process), and finally
origination of these vessels. the aortic and mitral valve again at the Botkin-Erb point.

is best heard at the heart base because. s. As distinct Intensity of the first heart sound diminishes in the
from the first sound, the second sound is shorter and mitral and aortic valve insufficiency. The cusps of the
higher. affected mitral valve fail to close completely the left
atrioventricular orifice during systole. Part of the blood
PATHOLOGIC HEARD SOUNDS: is thus regurgitated to the left atrium.
- The third sound is caused by vibrations during The first sound increases at the heart apex if the left
passive filling of the ventricles with the blood ventricle is not adequately filled with blood during
from the atria during diastole of the heart; it diastole. The first sound often becomes louder in
arises in 0.15-1.12 s from the beginning of the stenosis of the left atrioventricular orifice, when less
second sound. than normal amount of blood is discharged from atrium
- The fourth sound is heard at the end of to the ventricle during diastole. The muscle of the left
ventricular diastole and is produced by atrial ventricle is therefore less distended by the blood by the
contractions during quick filling of the start of systole; it is more relaxed and contracts more
ventricles with blood. rapidly and energetically to intensify the first sound.

The second sound over the aorta is diminished in aortic

AUSCULTATORY AREAS: valve affections, the cusps of the valve are destroyed or
their vibrating power decreases due to developing
1. area of the apex beat - for the mitral valves cicatrices. The second sound diminishes over the aorta
because the vibrations are well transmitted by
in cases of marked hypotension; the second sound slit formed by incomplete closure of the cusps of the
diminishes over the pulmonary trunk in cases of aortic affected valve (regurgitation murmur).
valve incompetence (in very rare cases).
Systolic murmur due to mitral valve incompetence is
The second sound may increase (accent) The aortic best heard at the heart apex. It can be transmitted by
second sound is accentuated when the blood pressure in the firm muscle of the left ventricle to the axillary area
aorta increases (in essential hypertension, during heavy or by the course of the backward blood flow from the
exercise, in psychic excitation), because during early left ventricle to the left atrium, i.e. into the second and
diastole, the aortic valve cusps are closed with a greater third interspace, to the left of the sternum.
force due to increased blood pressure in the aorta.
Diastolic murmur generated in a narrowed left
The high second sound in pulmonary artery occurs when atrioventricular orifice (stenosis) is usually heard over a
pressure in the lesser circulation is elevated or when the limited area at the heart apex.
vessels of the lesser circulation are overfilled with blood
Systolic murmur due to stenosed aortic orifice is heard
(e.g. in mitral heart diseases), disturbance circulation in
in the second interspace, to the right of the sternum. As
the lungs and stenosed pulmonary artery (in lung
a rule, it is well transmitted by the course of the blood
emphysema or pneumosclerosis).
flow onto the carotid arteries. Since this heart defect is
CARDIAC MURUMUS: Can be endo and exocardiac. characterized by a rough and loud sound, it can be
determined in auscultation over the entire heart region
- Endocardiac murmurs can be: These may occur
and be transmitted to the interscapular space.
in anatomical changes of the structure of the
heart (organic murmurs) or in dysfunction of Diastolic murmur due to aortic valve incompetence is
the intact valves (functional murmurs). better heard not over the aortic valve but rather at the
Decreased blood viscosity (e.g. in anemia) Botkin-Erb point, where it is transmitted by the back
increases the flow rate of blood and can also be flow of blood from the aorta to the left ventricle.
the cause of murmurs.
Properties of functional murmurs help differentiate
Systolic murmur: during systole, blood moves from one them from organic murmurs:
chamber of the heart to another or from the heart to
(1) in most cases of functional murmurs are
the main vessels and meets an obstacle. Systolic
systolic;
murmur is heard in the stenotic orifice of the aorta or
(2) functional murmurs are not permanent and
the pulmonary trunk because blood ejected from the
may arise and disappear when the person
ventricles meets a narrowed vessel (ejection murmur).
changes his posture, after exercise and during
Or in cases of mitral and tricuspid incompetence
various respiratory phases;
(regurgitation murmur). Generation of systolic murmur
(3) they are mostly heard over the pulmonary trunk
is explained by regurgitation of blood which is not
and less frequently over the heart apex;
completely expelled into the aorta and pulmonary trunk
(4) functional murmurs are transient and are rarely
during the ventricular systole, but is partly returned to
heard during the entire systole; these are soft
the atrium through an incompletely closed mitral or
and blowing sounds;
tricuspid orifice. Since this partly closed orifice is
(5) the murmurs are normally heard over a limited
actually a narrow slit, murmur is generated as blood
area and are not transmitted to long distances
passes through it.
from their source;
Diastolic murmur occurs if blood meets a narrowed (6) functional murmurs are not accompanied by
passage during diastole (ejection murmur). This other signs of valve affections (e.g. enlargement
murmur is heard in a stenosed left or right of the heart chambers or changes in the heart
atrioventricular orifice, since blood meets a narrow sounds).
passage in its flow from the atria into the ventricles.
Diastolic murmur also occurs in aortic or pulmonary
valve incompetence. Murmur is generated when blood
flows back from the vessels into the ventricles through a